Answer

Is hypertension a serious condition?

Hypertension is the most under treated cardiovascular condition. It can lead to heart disease, strokes and other health problems. Yet, according to a 1997 study by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, only 27 percent of individuals with high blood pressure are adequately controlled, leaving millions of others at risk of health problems, according to statistics in the USA. Physicians need to be more aggressive in controlling hypertension with medications, and the public needs to be made more aware of the risks.

What is considered a normal blood pressure for me? Does blood pressure go up with age?

Although doctors define high blood pressure as a blood pressure above 140/90 mmHg, we know that if you are otherwise healthy and not on blood pressure medications, the lower your blood pressure the better off you are, and the longer your life expectancy. Blood pressure is very variable, and is influenced greatly by activity, foods, and medications. Although there are no absolute rules for what constitutes a normal blood pressure, 120/80 mm Hg is considered desirable for adults without hypertension. For individuals with hypertension, a desirable blood pressure on treatment is 135-140/82-86 mm Hg. Blood pressure does not necessarily go up as we get older. Hypertension (defined as blood pressure greater than 140/90 mm Hg) is more common in older individuals, and isolated systolic hypertension (elevated 'top number', with normal diastolic, or 'bottom number') is especially more common in the elderly.

It is particularly important for women to have their blood pressure regularly monitored as part of every check up. Home monitoring, which is recommended today by many physicians for their patients with high blood pressure, not only helps physicians gauge the effectiveness of treatment, it also can weed out people suffering from "white-coat" hypertension.

Fortunately, strides have been made in home monitoring devices. Self-inflating blood pressure monitors that use microprocessor chips as sensors are more reliable and easier to use than older models, and they are less expensive to make and sell. Portable monitors can be worn throughout the day if fluctuations in blood pressure are suspected. A talking monitor with a voice readout recently became available for the visually impaired so they, too, can monitor at home.
These advances in technology and treatment must be accompanied by better awareness, especially among women. Attention to gender differences will make it possible to improve the quality of care and to reduce the risks of strokes, kidney damage and heart disease.

Many people have irregular heartbeats, and many people have hypertension. It is important to be able to measure blood pressure accurately in the presence of an irregular heartbeat.

The heart contains it own pacemaker. There are specialized cells in the heart that determine the number of heartbeats per minute that the heart will make. The net result of a heartbeat is that the chambers of the heart contract in a synchronous fashion, and blood is pumped throughout the circulation. The heartbeat is easily detected by feeling an individual's pulse in the wrist or in the neck, or by listening to the front of the chest with a stethoscope. Normal hearts beat at a rate of between 60-90 beats per minute, and the beats are regular. This means that there is a uniform period of time between each heartbeat. A disorder of the heart rate, or of the interval between heartbeats is called an arrhythmia. A disorder of the heart rate is either a bradyarrhythmia, which means the heart beats too slowly, or a tachyarrhythmia, which means the heart beats too rapidly. If the interval between heartbeats is altered, then this is called an irregular heartbeat. Other descriptive terms for irregular heartbeats include extra beats, extra systoles, premature beats or premature contractions. An individual may become aware of irregular heartbeats and have a sensation of palpitations or fluttering in the chest. Normal persons may have irregular heartbeats occasionally. Certain medications or foods (caffeine, alcohol) may increase the frequency of irregular heartbeats.

There are several heart disorders that are characterized by irregular heartbeats. One of the most common is called atrial fibrillation. In this disorder, the pacemaker of the heart is not functioning normally and instead of a regular heartbeat, the heartbeat is irregular. In other words, there is a variable interval, instead of a fixed interval between heartbeats. This condition may be due to coronary artery disease, overactive thyroid, or there may be no detectable cause. Individuals with high blood pressure are more likely to have this condition. This condition is often not associated with serious consequences, however it does require treatment. The first treatment may be directed to changing the heart rate back to a normal regular beat, so called normal sinus rhythm. This is usually only attempted if an individual has not had the condition for very long, since the longer atrial fibrillation is present the less amenable to conversion to normal sinus rhythm. Another aspect of treatment is to control the rate ?in other words keep the rate in the target range of 60-90 bpm. Finally, blood thinners are sometimes recommended for this condition, since an irregular heart beat may lead to blood clots in the heart, which then may lead to a stroke.

We know that people who have diabetes are at greater risk for developing hypertension. We are not sure if the reverse is true - that is, whether or not individuals with hypertension are at greater risk for diabetes. Some hypertension experts believe that in certain individuals with high blood pressure there is a greater propensity to be resistant to the effects of insulin. This phenomenon, called insulin resistance, is also associated with diabetes. Thus, in some cases hypertension may in fact be associated with an increased risk for diabetes, but more research needs to be done in this field. Regardless of the links between hypertension and diabetes, we know that more people are developing diabetes than ever, because of the rise in obesity, and more sedentary lifestyles. Thus, all Americans should be concerned about the possibility of developing diabetes and should make every effort to maintain ideal body weight and to exercise regularly. Those with hypertension should be especially concerned about the possibility of developing diabetes, since the presence of these two risk factors increases the risk of cardiovascular disease to a greater degree than either one alone.

The increased prevalence of diabetes in the affluent countries has received considerable attention in recent years. Along with a greater prevalence of obesity in, diabetes, particularly diabetes in older persons, is on the rise. This is a serious public health problem because people with diabetes are at much greater risk for strokes, heart attacks, and kidney failure. These risks are magnified if hypertension is present, and thus blood pressure control is as important as blood sugar control in people with diabetes. We know that those individuals with diabetes should have their blood pressure lowered to levels that are lower than those recommended for patients with hypertension without diabetes. The "target" blood pressure for a patient with diabetes is less than 135/85 mmHg. Achieving blood pressure control is especially important in patients with diabetes who show signs of kidney damage, since lowering blood pressure has been shown to protect the kidneys from further damages. All blood pressure medications are safe in diabetic patients.

At the present time, we believe that it is not how you lower the blood pressure, but whether or not you do that is important, although this is an area that is being actively investigated. In patients with kidney disease, angiotensin converting enzyme inhibitors should be part of the treatment regiment since these drugs have a beneficial effect of kidney function.

What is "White Coat Hypertension"? How can an Ambulatory Blood Pressure Monitor help detect "White Coat Hypertension"?

It is not unusual for blood pressure measured in the doctor's office to be higher than blood pressure measured at home during normal activities. The more comfortable a person is with the office surroundings, the more likely the blood pressure in the office will be close to the blood pressure measured at home. However, it is estimated that 20-25 % of patients with mild hypertension in the doctor's office (140-160/90-104 mm Hg) have what is called "white-coat" or isolated office hypertension.

White coat hypertension is not as dangerous as sustained hypertension (hypertension which is present all the time). However, individuals who have white coat hypertension may have a higher risk of complications and cardiovascular disease than those with completely normal blood pressure all the time. Another risk of white coat hypertension is that individuals with this condition may develop sustained hypertension at a later time.

There are several reasons to identify white coat hypertension and to distinguish those individuals whose blood pressures are only elevated in the doctor's office and are normal at all other times. The most important reason is to prevent unnecessary treatment of hypertension. If blood pressure medication is prescribed to a person who only has elevated blood pressure in the doctor's office, then the treatment may cause low blood pressure at all other times, which may result in fatigue and light headedness. Second, it is also useful to identify whether blood pressure elevations are simply isolated to the doctor's office, or whether they are present at other times as well, for example, at work.

Ambulatory blood pressure monitoring is a technique that involves automated inflation of the BP cuff and recording of the BP at 15 to 20 minute intervals throughout the day and every 30 to 60 minutes during sleep. This technique permits identification of those with white coat hypertension. It also permits a more comprehensive assessment of the blood pressure profile of an individual throughout the day and night. These parameters are important in determining how to best treat hypertension.

Women of all ages are disproportionately afflicted by a common condition known as "white coat" hypertension, in which their blood pressure rises significantly in the doctor's office - anywhere from 10 to 30 points - yet remains normal at home and work. This "false positive" response may be an involuntary conditioned reflex to the anxiety of being tested, according to recent studies, and strikes somewhere between 20 percent and 39 percent of patients diagnosed with mild-to-moderate hypertension. Those with normal readings at home are believed to be at no greater risk for health complications and could be taking blood pressure medications needlessly.

Who is at greater risk of having high blood pressure - a man or a woman?

Many women are surprised to learn that, after age 59, they are more likely than men to have hypertension, and their risks continue to increase at a faster pace as they age. Even more alarming, dangerous complications such as strokes and kidney problems caused by prolonged high blood pressure occur at the same rate in women as in men, while the risk of developing heart disease lags only a little behind that of their male partners.

Reasons for gender differences in blood pressure are not known but are being investigated by many scientists. It has been suggested but not proven that estrogen is responsible for the lower blood pressure in younger women, but the relationship between estrogen levels and blood pressure is complex. While numerous studies have shown that hypertension is twice as prevalent after menopause, it is unclear whether the increased risk is caused by the drop in estrogen or by other factors such as weight gain, decreased physical activity and increased alcohol intake. Adding fuel to the controversy is a study in Finland that showed women who had undergone hysterectomy had higher blood pressure than women who had not undergone hysterectomy, even when their estrogen-producing ovaries were left intact.

High blood pressure during pregnancy is a common problem. It may be due to either preeclampsia (toxemia), which is a disorder of late pregnancy characterized by elevated blood pressure and protein in the urine, or it may be due to hypertension that was present prior to pregnancy (chronic hypertension). Both conditions are associated with risks of premature delivery, low birth weight babies, and occasionally bleeding. Blood pressure should be monitored closely during pregnancy, particularly if a woman has a history of high blood pressure.

Younger women need to know about increased risks for hypertension associated with pregnancy, obesity and contraceptive pills. Pregnant women have estrogen and progesterone levels 50 to 100 times higher than normal and, indeed, blood pressure decreases during pregnancy in most women, as would be expected. However, high blood pressure complicates as many as one in 10 pregnancies and can progress to preeclampsia, a dangerous condition in which convulsions can threaten the lives of both mother and baby. Clearly, other variables besides estrogen are at work.

Can birth control pills reduce my risk of developing high blood pressure?

One would assume that birth control pills, which contain estrogen, would lower blood pressure. However, the estrogen in oral contraceptive pills causes a small but detectable increase in blood pressure in most women, which means that hypertension is two to three times more common in women on the pill. The Walnut Creek Contraceptive Drug Study, which included 11,672 women, showed an increase of 5 to 6 points in systolic blood pressure (the higher of the two readings) and 1 to 2 points in diastolic pressure for white women, with African-American women experiencing less of an increase. That risk becomes greater with age, duration of pill use and increased body mass.

A prudent approach to oral contraceptive use is to monitor blood pressure at least every 6 months. If high blood pressure is found, then a decision to discontinue the pill should be based on the degree of hypertension, the potential hazards of pregnancy, and the individual's risk of developing heart disease.

The effects of hormone replacement therapy on blood pressure are not as clear cut as the effects of oral contraceptive pills. Perhaps because the dosages are lower, the increase in blood pressure is not as consistently observed, and some studies have even documented a decrease in blood pressure. Preliminary evidence suggests synthetic progestin increases sodium retention. But a three-year study of women ages 45-64 using a variety of hormone replacement therapies showed no differences in blood pressure in any of the treatment groups compared to the placebo group. These women started out with normal blood pressure, however, and it is not known how women with high blood pressure would fare over time. More studies are needed.

What lifestyle changes can I make to reduce my chances of developing high blood pressure or to lower my pressure if it is already high?

The good news for women is that hypertension responds well to diet changes and weight loss, or to medications when lifestyle changes aren't enough. Obesity merits especially close watching because it is significantly more common in middle-aged women than men. Furthermore, body weight has a greater impact on blood pressure in females than in males, according to new evidence.

When it comes to dietary changes, studies have shown women's blood pressure readings respond slightly better than men's to lowered salt intake, while abundant fruits, vegetables and low-fat dairy products are beneficial to health in general. On the flip side, excessive alcohol - which means more than two or three drinks per day - is associated with increases in blood pressure, and most studies have shown that it takes less alcohol to have toxic effects in women than men.

Studies of the benefit of exercise to reduce blood pressure in women are scant. However, given the beneficial effects of exercise on weight control, prevention of osteoporosis, and insulin and glucose metabolism, women with hypertension whose heart function is normal would do well to exercise regularly.

Medications are an important addition to the arsenal of weapons against high blood pressure. The health benefits of medications to lower blood pressure have been observed most clearly in African-American and elderly women, although the cardiovascular benefits in women have not been studied separately from that of men. Reduction in strokes was clearly noted in women who participated in large clinical studies, but the impact of medications on overall death rates is less clear.

It has been clearly demonstrated that treatment of hypertension prevents strokes, heart attacks and deaths from cardiovascular disease. This has been shown by studying thousands of patients with hypertension and enrolling them in clinical trials in which the effects of anti hypertensive treatment has been compared to either placebo (inactive medication), or a less rigorous treatment approach. The studies that demonstrated the beneficial effects of blood pressure lowering medication were conducted over the last 25 years, and the drugs utilized were diuretics and beta blockers. Many physicians treat hypertension in the year 2000 with more recently developed drugs such as angiotensin converting enzyme inhibitors, angiotensin receptor antagonists and calcium channel blockers. These drugs compare favorably with diuretics and beta blockers with respect to their ability to lower blood pressure.

However, so far, less information is available regarding the ability of these drugs to prevent strokes, heart attacks and deaths from cardiovascular disease. This situation will change in the near future, because a very large clinical trial now in progress called the ALLHAT trial will be completed in the next few years. In this trial, the newer drugs will be compared with the older drugs to determine if they have the same long term benefits in patients with hypertension. Until the results of this study is available, it is good practice to treat hypertension with diuretics and beta blockers. However, since most patients need more than one medication to lower their blood pressure to normal, the newer agents are often very effective, and well tolerated. Furthermore, in patients with kidney disease, particularly diabetic kidney disease, angiotensin converting enzyme inhibitors are effective in slowing the progression of kidney disease.